All nursing centers receive visits from their state survey agency at least once a year for the annual survey process, and most also have periodic complaint surveys either from self-reporting events or because of actual resident or family complaints to the agency. 

Sometimes the survey process reveals significant areas where a nursing center can improve its procedures and care, and ideally the goal of the survey process is to do just that: help teams provide better care. Unfortunately, the reality of the survey process may feel adversarial rather than collaborative, with a perception that surveyors come in with a “Gotcha” mentality and often write deficiencies that have nothing to do with the quality of care.

The bulk of most state survey agency teams consists of nurses, although other professionals (for example, dietitians, pharmacists) may be on an individual team. Usually, there is no physician involvement from the state agency, except in complex situations or those where there is a significant bad outcome, and in those cases the state agency’s physician usually participates remotely and after the findings have been made.
But the nursing center has a valuable ally who can be of great benefit in navigating real-time interactions with the survey team: the medical director. The depth of the medical director’s clinical knowledge, combined with familiarity with the nursing center’s individual characteristics, self-assessment, and case mix, can be a formidable resource when surveyors have questions and concerns about clinical or facility process-related factors.

A Broad Role

The medical director’s role under Centers for Medicare & Medicaid Services (CMS) regulations is painted with a broad brush: implementation of resident care policies and coordination of medical care within the nursing center. This is a tall order, and a frank appraisal may quickly reveal that the medical director is not really filling the order in many nursing centers.

Medical directors are expected to attend the federally required Quality Assessment & Assurance (QA&A) meetings and to serve as a liaison between the nursing center’s administration and other physicians and other licensed independent practitioners who tend to residents there. The medical director should also review and provide input into policies and procedures to ensure they are up to date and appropriate.

Typically, the medical director serves as an independent contractor to the nursing center, with a set number of budgeted hours. These hours are for administrative time as medical director, not caring for residents, and the hours may be between five and 20 monthly. It should be an expectation that nursing centers’ medical directors make themselves available to meet with survey teams anytime they are in the center, but especially during the annual survey. Surveyors are instructed to assess whether the medical director is involved in the QA&A and the Quality Assurance/Process Improvement (QAPI) efforts within the center.

Making Survey a Priority

Even if the medical director has an office practice or other commitments, the nursing center should make it clear that it is a priority for the medical director to make direct contact with the survey team—if under unusual circumstances the medical director cannot make it in person during survey hours, then a phone call to introduce themselves and provide contact information if questions should come up during the survey are the least a medical director should do.

Whenever possible, the medical director should attend the exit conference—it shows a lot about the level of commitment the nursing center and its medical director have to quality care and remaining in substantial compliance with the regulations.

When surveyors give the impression that they are contemplating writing a deficiency about a particular resident, it may be appropriate to ask the medical director to review the chart and discuss the concerns with the surveyors. Sometimes this can make the difference between an actual harm-level deficiency and a potential for harm, and sometimes it can actually result in no deficiency being written. Obviously, it is important for the medical director to be well versed in both clinical, medical, and pharmaceutical matters, but also to understand the regulatory framework under which nursing centers operate, including federal and state regulations.

Many medical directors lack this knowledge, and one excellent resource for gaining that expertise is through the educational offerings of AMDA – The Society for Post-Acute and Long-Term Care Medicine, (formerly known as the American Medical Directors Association), and its state affiliates. It would behoove nursing center administrators to encourage, or even insist contractually, on their medical directors obtaining Certified Medical Director status through the American Board of Post-Acute and Long-Term Care Medicine (ABPLM, to help ensure a baseline level of knowledge on medical direction.

Aiding With Disputes

Beyond the survey, the medical director can be invaluable in helping draft Plans of Correction after deficiencies are written, and even more in pursuit of informal dispute resolution (IDR) when a deficiency seems unfair or excessive in scope and severity. Almost all nursing centers have experienced deficiencies that they felt were inappropriate, and a written statement or declaration from the medical director can often lay out the medical and clinical factors that make the deficiency excessive in a way that is authoritative, educational, and compelling. This should be another function of a competent, engaged medical director, and nursing centers should not hesitate to request this kind of assistance.

Beyond the IDR process, if there is a formal appeal of a deficiency such as a local court proceeding, the medical director’s input is even more important. The credibility of a physician can go a long way toward helping a trier of fact—usually a lay person with limited medical knowledge—and direct testimony from the medical director can be the critical factor in prevailing on these regulatory cases.

Again, solid knowledge of the regulatory framework is essential, as is an ability to understand and explain difficult concepts like the natural progression of certain disease processes, unavoidability, and the causal relationships (or lack thereof) between certain nursing center actions or omissions and a particular bad outcome.

Options for Improvement

If the nursing center does not have a medical director who can fulfill these relatively simple, expected functions, there are two reasonable options to remedy the situation. First, insist that your medical director get up to speed on the regulatory aspects of the care setting, and that they are willing to commit to assisting directly in the survey process—including a formal written set of expectations and educational requirements, similar to the way an employee would be expected to remediate—and with consequences for not fulfilling these obligations.

Or, replace the medical director with someone who does have the requisite knowledge and commitment to help the nursing center in these ways—usually a certified medical director or at least a person who regularly attends professional meetings with AMDA and its state affiliates.

Although a geriatrician is the ideal fit for a medical director, there are several reasons why a nursing center might desire a medical director who is a hospitalist—there is a direct connection to the local hospital, and there can be continuity of care within a hospitalist medical group. But keep in mind that many hospitalists only want to be involved with the skilled, post-acute population, and may eschew caring for the traditional, chronically ill custodial long term population. And hospitalists often know little to nothing about how skilled nursing centers operate, although they can certainly learn.

Again, it is not inappropriate, and perhaps especially important, for a nursing center administrator to ask a hospitalist medical director to become an AMDA and state affiliate member and to access the necessary educational meetings and online resources to become a truly high-quality team member who can lead the nursing center to clinical excellence and regulatory compliance.

In these days of Patient-Driven Payment Model (PDPM), it is all the more critical for nursing centers to have knowledgeable medical directors. A great medical director can help with the survey process, and so much more. If a nursing center doesn’t have one, it should look into finding one or creating one.
Karl Steinberg, MD, CMD, HMDC, is president-elect of AMDA –The Society for Post-Acute and Long-Term Care Medicine, vice president of National POLST, chief medical officer for Mariner Health Care, and a long-time skilled nursing center and hospice medical director and attending physician from Oceanside, Calif. He is also a certified health care ethics consultant and takes his dogs to work on most days.